Guest Column

The Future of Rutgers Healthcare

By ANNA AND PETER MERRETT

February 10, 2018 at 4:15 AM

Credits: Anna Merrett

Credits: Anna Merrett

Credits: Anna Merrett

By ANNA AND PETER MERRETT

February 10, 2018 at 4:15 AM

Last week, Rutgers University Alumni Association organized a cocktail hour and an evening of conversation between the University President Robert Barchi and his guests at the Grand Summit Hotel. Brian Strom, the Inaugural Chancellor of Rutgers Biomedical and Health Services and the Executive Vice President for Health Affairs at Rutgers joined Barry Ostrowsky, President and Chief Executive Officer at RJWBarnabas Health, New Jersey's largest, most comprehensive integrated healthcare delivery system. About two hundred people were in attendance and had a chance to network with fellow alumni and learn about the university's outlook for the future of healthcare both at Rutgers and in New Jersey.

This was one of a number of alumni networking events, hosted by Rutgers University. President Barchi initiated the idea of inviting various members of the university faculty to share their insights at each gathering. Previous conversations included addressing climate change and cybersecurity as well as the economy and banking. President Barchi, who has held his position for almost six years, began by listing some encouraging numbers. In 2012, Rutgers University had about 58,000 students, as of this year, 70,000. In 2012, the university awarded 13,900 degrees, last year 17,700; in 2012 the university budget was $1.9 billion, this year it amounts to $4.4 billion. In 2012, $95 million were raised in philanthropy, in 2017, the figure reached $205 million. "We need to keep moving up!" The compound annual growth rate for tuition 2007-2012 was 4%, and in the last five years, it has been under 2%. The president noted how important it is to keep the tuition down, making sure it is affordable to all students. He pointed to new buildings being constructed throughout the campus, "We are finally providing physical plant where the faculty can work, our students can learn and our community can be proud of." In 2012, Rutgers did not have any medical schools and now it has two. To the cheering crowd, Barchi announced two statistics: "Two years ago, the National Rankings that came out in USA Today, ranked Rutgers number two in the nation for undergraduate health science education. This year, Rutgers is ranked number one in the nation." President Barchi thanked everyone for coming and the alumni for the continued support of Rutgers University and he asked his guests what, in their opinion, were the biggest changes in healthcare within the past decade.

Barry Ostrowsky began "From our industry, which was typically described as the 'hospital industry' for the better part of the century, we focused exclusively on big buildings and making sure we had every bed filled. It was frankly a very arrogant industry, it did not have a great interest in dealing with the consumer or the patient or his or her family in any meaningful way. There was never a sufficient amount of integration between the institution and its physicians." There was insufficient camaraderie among the physicians for the benefit of the patient. The patient was not at the center of activity for decades. The healthcare industry was lacking consumer movement so the typical response to any questions regarding their care was: "Look, this is too complicated for you to know anything about. You just have to take what we give you." "So there is and has been a radical shift, thank God, that our industry has been dragged into, which is to acknowledge, that the only reason we are in business is to service the patient, and if we are going to in fact service the patient in an effective way, we are going to have to marshall all of the participants, ensure that there is an effective team, and have to talk about health care to our patients. We have to be less concerned about the historic approach of inpatient care versus home and outpatient care, and need to carve into the 21st century, by incorporating new technology by way of communication, data gathering and analysis. So what we are saying right now is that we are in a rush to catch up to most other industries that have gone through this evolutionary cycle, and, as a result, I think we will be the beneficiaries as consumers, of better, more efficient and more reliable care. So I think the big difference if I had to try to coin a simple sentence is that there is finally an acknowledgment that it is the patient that makes the most difference, it is the patient that we have to serve."

Brian Strom pointed out "The biggest change is the advent of population based care otherwise referred to as value based care." "We as practitioners are beginning to bankrupt the country." The continuous increase of the cost of care has been noticed by everyone. What can be done to change that? "More and more people are thinking about population care, where you adopt a population of patients, and you pay for the cost of their care on a per person, per month basis, so that all of a sudden your incentive isn't to do too much, the risk is the incentive to do too little, because now at any time people are hospitalized, hospitals go from the profit centers to cost centers. Radiology, surgical procedures, all things that we did more of, the MRIs, CAT scans, and paid more for, now become cost, and cost to the provider, because the providers are the ones taking the risk. The risk is the opposite of the traditional risk service. A lot of work has been done to begin to measure value. How do you measure value? How do you measure quality? How do you make sure people are getting the kind of care that they should be getting? There is a huge need for data in order to do that, newer technology, infrastructure data wise, electronic health records with the ability to be able to see if you are providing the care you are supposed to with penalties if you don't. Right now we are in transition. New Jersey is behind some other states in this process. It is very rapidly changing. We are seeing aggregates of hospitals, because to take these kinds of risks we need a large organization, we need to care for the entire population of people, we need to be paying attention to keeping them healthy instead of passively waiting till they get sick." "Now when a patient gets sick, as you move to population care, that costs you money instead of makes you money, so your job as a healthcare provider has changed, and it is to prevent people from being hospitalized, prevent them from getting sick."

President Barchi addressed the speakers: "We are looking for outcomes more than just the activities themselves. In population health you are looking at the aggregate health in populations which means you should have access to the populations, so it means people have to have healthcare because preventive care becomes the critical part of the equation. What else I see in my own years of having practiced medicine, is the shift in emphasis towards quality in consumer identification and knowledge about the outcome. Patients now go online and see what the surgical outcomes are and they do shopping for their procedures not just based on what their friends say about how well somebody did their surgery and how well they were treated, but what do the numbers say. How many procedures does doctor X do a week or a month and what is the infection rate, what is the outcome rate. What is the quality rating for the hospital." President Barchi expressed surprise that his two guests did not bring up the buzzword "personalized medicine."

Brian Strom responded that one of the problems in traditional clinical trials is that they rely on averages. A given drug may work for 50% of the population, so researchers now are focusing on narrowing this percentage down, so the drug can be only administered to people for whom it will work, resulting in much more effective treatment. "That is what is commonly referred to as personalized medicine, that you are tailoring the medication to a person. It is an approach which has been best developed in cancer and The Cancer Institute of New Jersey at Rutgers has been one of the nation's leaders in doing that." Researchers look at the genetics of cancers, at the disease source, because a gene abnormality a kidney cancer has, a lung cancer may have as well, and so a very specific medication may be applied as opposed to a generic cocktail and chemotherapy, often toxic to patients. Metabolomics, where the scientists examine the chemicals in the body that get metabolized in the urine for example, then look at how the body handles its normal exposures. There are suggestions that metabolomics like genomics, may be useful in trying to personalize a treatment for heart and other diseases. Personalized medicine so far, has been most effective in treating cancer, but it will also be applied to other diseases.

President Barchi pointed out that the phenotype of the patient responding to a particular drug, and genomics of a given disease are great examples of personalized medicine. In addition "One of the most exciting things, which came out in the past five years, is using your personal cells to be genetically engineered to be your medicine."

Barry Ostrowsky replied "When you are sick all of this is particularly relevant, but the goal here is to stop you from getting sick, and our organizations in our industry basically rejected the notion. After all it is counterintuitive from the business standpoint, its very difficult for us to collect any revenue when you stay healthy all the time. So our industry really never spent a lot of time on preventive care, and by the way, we don't label going out to the community to do the screening as preventive care. Screening was the most effective sales force we had; when we had 200 people come, we could find at least 40 patients in 200 people, so it had nothing to do with keeping people healthy. The mission of our organization took a radical change in part thanks to my two colleagues who are board members of ours, because we have decided, yes, healthcare is important, vending those services is important, understanding the science is critical, but we should be judged by how healthy the community is, not how many sick people we have helped. We can keep score on that and we certainly need to do a better and better job, but ultimately our goal is to be able to say this community of five million people in our service area has the quality of life that includes a health status that's as good as you can have anywhere in the country and maybe in the world. It is not about healthcare service; ten percent of the health of the community is genetics, thirty percent is what we do, selling you services, delivering services, sixty percent is the social determinant, some of which is involuntary and some of which is voluntary. If you live in Short Hills, have terrible diet, smoke, don't sleep and don't get exercise, I don't care what we do for you in the emergency department, or how good our surgeons are, you are not going to be in a good health. You may beat the wheel for a period of time, but if you keep that up, you are not going to be in good health. If you live in a vulnerable community, and we have many people living in vulnerable communities in our service area, maybe most notably Newark, though we have similar demographics in New Brunswick, Lakewood, Long Branch and the like. People there involuntarily face social determinants. So if we are going to be effective in the health world, we are going to have to do something that just simply makes great health care service available. We are going to have to address food insecurity and food deserts, chronic unemployment and improve the quality of housing." Insurance companies and federal programs do not address these issues. "Why not include in the Medicare Program a simple payment for us to 'seniorize' the house. We will do the inspection, we actually will put together a program, we will put in railings, we will test the lights, do all that." This can be done for $3,000 versus paying $48,000 for a serious injury. Social Security said it is not a part of their program. "You can prune out 60% of accidents with such prophylactic investment by making the residencies safer. We do not have that kind of policymaking." Improving the living conditions and environment will dramatically reduce their need for hospitalization. Barry Ostrowsky's organization is beginning to address these issues on its own, without outside funding.

The guests answered several questions from the audience and the meeting ended in thunderous applause.

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